(A) Aortic stenosis is divided into congenital and acquired aortic valve stenosis.
Congenital aortic stenosis accounts for about 2/3 of the patients with aortic stenosis, with bifid valve malformation being the most common, accounting for more than 50% of adult aortic stenosis. Acquired aortic stenosis is more common as rheumatic aortic stenosis, accounting for 30-40% of all aortic valve replacement patients.
Age 60 years or older, degenerative aortic stenosis is the most common.
1. Indications for surgery for congenital aortic stenosis
(1) Patients with aortic stenosis in infants and children, with an orifice area <0.4 cm2 and aortic valve transvalvular systolic peak pressure difference >10 kpa (75 mmHg), called severe stenosis, should be subjected to emergency surgery for valve leaflet junction dissection. Otherwise, heart failure and sudden death are very likely to occur.
(2) In mild or moderate stenosis, the following conditions should be operated.
(1) Those with recurrent clinical syncope or angina pectoris;
(ii) with exercise palpitations, shortness of breath, left heart hypertrophy and strain on ECG, systolic tremor felt in the second intercostal space at the right edge of the sternum, and measurement of aortic valve pressure gradient >6 or 7 kpa (50 mmHg);
③Valvular calcification or bacterial endocarditis, combined with insufficiency of closure.
2.Surgical indications for acquired aortic stenosis
(1) When the effective orifice area is <0.7 cm2 and the transvalvular pressure step difference is >6.7 kpa (50 mmHg), surgery should be performed regardless of whether there are symptoms or not and whether the left heart function is impaired.
(2) Patients with aortic stenosis should be operated for a limited period of time if the following conditions are established by examination
(1) Severe stenosis of the valve and a transvalvular pressure step difference >10kpa (75mmHg);
(ii) Occurrence of left heart failure;
(iii) Frequent syncope and angina pectoris. Because of the above conditions, the patient is prone to sudden death.
(3) Moderate valvular stenosis ECG shows progressive hypertrophic left ventricular strain, and ultrasonography proves progressive aggravation of ventricular wall hypertrophy, which should be treated surgically.
(4) Patients with aortic stenosis combined with valve leaflet calcification, incomplete closure, or endocarditis should undergo surgery promptly.
(5) Patients with hypertrophic left heart strain with pulmonary venous hypertension and left ventricular systolic function to appear to be decompensated should be operated.
(6) Due to other valve surgery, even mild aortic stenosis or pathological damage to the valve, the aortic valve should also be operated.
(B) Aortic valve closure insufficiency The etiology of aortic valve closure insufficiency is mainly in two categories.
1, valve lesions mainly.
Rheumatic disease is the most common, and non-rheumatic diseases include endocarditis, bilobed valve, VSD with valve leaflet prolapse, etc.
2, aortic lesions.
Such as Marfan syndrome, syphilis, aortitis, entrapment aneurysm, ruptured Valsalva sinus aneurysm, etc.
In developing countries, rheumatic disease is the most common; while in developed countries, aortic lesions predominate, accounting for 50% of AVR procedures for aortic valve insufficiency, while rheumatic disease accounts for only 25%.
3.Surgical indications of aortic valve insufficiency:
(1) symptomatic aortic valve closure insufficiency, the patient presents with dyspnea, exertional fatigue, angina pectoris, chest pain and other symptoms, is an absolute indication for surgery. However, for patients with LVESDLVESD > 60 mm, EF < 30%, ESVI > 90 ml/m2, the decision must be made with caution.
(2) Asymptomatic aortic valve closure insufficiency with the following indications should be operated.
①LVESD close to 55 mm (ultrasonography);
②LVPSWS<80,0kpa(600mmHg)(ultrasound);
③LVPSWS<30,1kpa(235mmHg)(ultrasound);
④FS close to 25% (ultrasound);
⑤EF close to 50% (ultrasonography);
(6) Shortness of breath after activity.
(3) How to deal with asymptomatic aortic valve incompetence that does not meet the above indicators on examination. It is generally advocated that LVESD 50-54 mm should be followed up every six months, LVESD 45-49 mm should be followed up annually, and <45 mm should be followed up every two years. If the left ventricular size reaches the standard or if left ventricular insufficiency occurs, surgery should be performed.